Application for Appointment

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Type of Appointment

Authority

Board

Commission

Committee

Are you willing to serve on more than one Authority, Board, Commission, or Committee?

Yes

No

First Choice

Second Choice

Third Choice

Gender

Male

Female

For diversity purposes only.

Ethnicity

For diversity purposes only.

Name

Email Address

Address

City

State

Zip Code

Phone Number

Fax Number

Business/Employer

Email Address

Address

City

State

Zip Code

Phone Number

Position

Are you a resident of the City of Roanoke?

Yes

No

Length of Residency in the City of Roanoke

Are you a registered voter?

Yes

No

Are your accounts current with the City (Taxes, Utilities, etc.)?

Yes

No

Are you over the age of 18?

Yes

No

Education

Volunteer and/or Community Involvement

Are you currently a member or have previously served on a Council-appointed Authority, Board, Commission or Committee? If yes, please specify.

Why are you interested in serving as a member of this Authority,board, Commission or Committee?

List any additional information which might qualify you for this appointment.

Do you or does any member of your immediate family residing in your household hold a position, paid or unpaid, with any person or entity, or have a contract with or any obligation to any person or entity, which might constitute a conflict or a conflict-of-interest with the position for which you are applying?

(For purposes of this question, “entity” specifically includes, but is not limited to, the City of Roanoke and any entity which receives funds from the City.)

Have you ever been convicted of a law violation, including moving traffic violations, since your 18th birthday?

Yes

No

Comments

Have you ever been convicted of a felony?

Yes

No

Comments

Have you ever been convicted of a misdemeanor involving moral turpitude (any offense involving lying, stealing, or cheating) since your 18th birthday?

Yes

No

Comments

Are there any criminal charges or proceedings pending against you?

Yes

No

Comments

By submitting this form, you hereby certify that the criminal information is true, accurate and complete.